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Comp should cover psychological evaluation: Court


A psychological evaluation should have been covered under workers compensation, the Supreme Court of Oregon held Friday.

In Matter of the Compensation of Garcia-Solis v. Farmers Insurance Co., in an en banc decision, the state’s high court reversed a Court of Appeals decision holding that an injured worker’s psychological referral was not covered by workers comp because she failed to prove it was related to the medical conditions the insurer accepted.

In 2009, Elvia Garcia-Solis was working as a food server in a tent when high winds blew down a tent pole, which struck her on the head and slammed her into a wall. She suffered from multiple injuries and was hospitalized. Her employer’s workers comp insurer, Woodland Hills, California-based Farmers Insurance Co., accepted her conditions including a clavicle fracture, rib and spine fractures, scalp laceration, elbow contusion, concussion, closed head injury, chronic headache syndrome, facial scarring and nerve injury. In January 2010, Ms. Garcia-Solis reported to her physician that she was experiencing psychological problems when it was windy. The doctor recommended a psychology referral to address the post-traumatic syndrome disorder-like symptoms, but Farmers refused to authorize the referral on the grounds that it was not causally related to any of the conditions that the insurer had accepted.

An administrative law judge ruled for Farmers, and the Oregon Workers Compensation Board affirmed the decision, holding that “compensable injury” meant only those conditions previously accepted by an insurer, and not necessarily all of the medical conditions caused by the work injury. Although the doctor said the psychology referral was caused “in material part by claimant’s accident at work,” the administrative judge held and the board affirmed that because she had not been diagnosed with PTSD, Ms. Garcia-Solis had not met her burden of proof. The judge, however, did note that Ms. Garcia-Solis was “effectively trapped” because she needed the psychology evaluation to determine if she had a mental health condition compensably related to her injury, but could not get the insurers to pay for the evaluation because she did not have a diagnosis “on which to premise a new medical condition claim.” The Oregon Court of Appeals affirmed the decision, but dissenting Judge James Egan concluded that Oregon statutes “explicitly” equate compensable injuries with the incident of injury rather than the conditions accepted by the insurer.

The Supreme Court of Oregon reversed and remanded the case. While the court held that the insurer correctly held that under Oregon statutes “compensable injury” only means accepted conditions, the court noted that the statutes mandate that an insurer provide “medical services for conditions caused in material part” by the compensable injury and requires the provision of medical services “directed to medical conditions caused in major part” by the compensable injury.

Although Farmers argued that in the statutes, the legislature used “compensable injury” to mean “accepted condition,” the court held that the insurers argument “depends heavily on an assumption of terminological consistency in the workers compensation statutes …” The court concluded that the “injury” is the work accident that caused the medical condition and resulted in the need for medical services, and is “not limited to conditions that the insurer has accepted at the time that medical services are sought.”

The court, therefore, reversed and remanded the case to the workers compensation board for further proceedings.

Farmers Insurance did not immediately respond to a request for comment. 




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